Robotic Assisted Surgery and The Barrier Limiting Its Adoption
Article written by?Anne Osdoit , CEO of Moon Surgical
The surgical robotics industry is on fire…. in a good way.
Just this year, we saw massive fundraising by Memic ($96MM), CMR ($600MM), and Vicarious ($1.1Bn).
One of the main drivers of this growth is the success of Intuitive Surgical, founded in 1995 by John Freund, Rob Younge, and Dr. Fred Moll. With its Da Vinci surgical systems, Intuitive's goal was to enable surgeons to perform laparoscopic surgery on soft tissues with increased capability and visualization.
Twenty-six years later, the US company has made over $34 billion in revenues, performed over 8.5 million procedures, and now supports a market capitalization of $127 billion.
But they're just skimming the surface.
In Intuitive Surgical's 2021 J.P. Morgan presentation, CEO Gary Guthart pegged Da Vinci's share of soft tissue procedures at just 6%, or 1.2 million of the potential 20 million addressable procedures. In addition, Mr. Guthart also stated that they foresee this growing to?to 6 million surgical procedures, which suggests that their current XI system's capabilities still do not support broader adoption [2].
Despite Intuitive Surgical’s renewed success, the value, effort, and cost of using the Da Vinci XI might not have reached a point that supports change in 94% of soft tissue procedures. This limited adoption explains why so many others, from large blue chip players to startups, have been working on developing alternative options.
Companies like Covidien (at the time), Medtronic, Google, J&J, and Boston Scientific have all had ambitious and cash-intensive general surgery robotics programs. None have succeeded in deploying a viable product in the market that rivals Da Vinci’s solution. Nobody has even come close.
Along the way, all of these contenders have all come to the same realization :
Building a successful surgical robotics platform is an arduous and risky undertaking.
What hurdles must be overcome to allow broader robotics platforms ? Where is the magic bullet ?
The key is?adaptability. But figuring out how to get there is incredibly complex.
The road to building a successful surgical robot is full of landmines: Huge expenses, technical challenges, and missteps that can result in substantial delays and exorbitant sunk costs. Take Johnson & Johnson's Ottava program. In J&J's Q3 2021 earnings call, Executive Vice President Joseph Wolk said [3] :
"We recorded a partial in-process R&D charge for?$900 million in the third quarter. The accounting for this charge contemplates a first-in-human delay of approximately two years from our earlier projections of the second half of 2022, reflecting technical development challenges."
Successfully navigating these hurdles requires the right team, mindset, and knowledge of the challenges ahead. But, most of all, it requires a laser focus on adaptability, driven from the C-suite down.
Adaptability?– There is a lot that goes into that word. A few days ago, I looked more deeply into the meaning of adaptability, versatility, and agility.
Consider the smartphone. It was designed with adaptability in mind: It has incredible computing power and is equipped with over 16 different types of sensors. We use our phones to monitor our workouts, pay for groceries, get us to a destination, and even authenticate our identity.?They keep us agile and efficient; one tool, multiple jobs.
In the operating room, a surgical team aims to be as agile as possible. Performing procedures with precision and efficiency minimizes risk;?every additional minute the patient is on the operating table is an additional minute of risk for infection, bleeding, and other complications. Agility supports faster patient recovery and helps maximize outcomes. In the end, an agile team can deliver a consistent quality of care because they can react quickly to changing situations.
For a surgical team to be agile, they must have versatile tools because things often do not go according to plan; no two patients are the same. Even anatomy varies substantially from one patient to the next. There are as many as ten "typical" anatomies described in surgical textbooks for procedures as simple as cholecystectomies.
To deliver versatility, tools must be conceived and engineered to be adaptable. They must be designed to change or be reconfigured to the needs of the surgery, the operating theatre, and the entire surgical team. Ideally, these tools should be able to understand their evolving environment and guide adjustments to keep effort minimal and efficient.
This is the Future of Surgical Robotics
Adaptability is the frontier that has kept adoption limited to 6% of the total potential procedures. Intriguingly, the interventions where meaningful adoption is achieved require a particular function: enabling fine dissection and suturing in constrained workspaces.
Prostatectomies take several hours and involve the manipulation of numerous instruments inside a deep and narrow space.
The value delivered here is confidence in the surgical technique (dissection & suturing) and ease of use for the surgeon. This value is significant enough to tolerate the robot's complicated set-up and the space it takes up in the operating environment.
In these specific indications with high market penetration, Da Vinci has had winner-takes-all success.
Today more than 75% of prostatectomies performed in the U.S. are done with a Da Vinci robot [4]. Many surgeons only operate on prostates with Da Vinci and would refuse to do so without it.
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For prostatectomies, robotics have become an essential element of surgical routine and operating rooms.
In other general surgery specialties and procedures, robotics adoption has been limited and sporadic. Surgeons and administrators alike often convey that it is "just not worth it."
There are direct costs: equipment, instruments, and service costs. And there are the indirect costs, which are personnel and opportunity costs.
Direct Costs
In his?The Cost of Robotics?paper published in the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) journal, Dr. Khorgami does a great job at covering the direct costs. He showed that current tele-robotic systems increased costs by 10-20%, depending on the procedure [5]. A table is shown below.
Indirect Costs
During our discovery process, we interviewed countless operating room (OR) managers.
The biggest issue with robotics? Set-up time. Even after getting through a significant learning curve, current tele-robotic systems are a nightmare to set up and position.
A rule of thumb applied in planning was adding 45 minutes to OR turnover for robotic cases. When something changes requiring a system repositioning within the procedure, even more time is lost. And for an OR, downtime is lost revenue.
The latest robotics systems all are trying to solve the challenge of adaptability. Some have decided to break up the robotic arms into smaller individual carts.
The idea is that modularity allows for increased versatility for different procedures, but the set-up complexity increases, as does the number of wires crisscrossing the operating theatre, a point of significant frustration for surgical staff.
Whether boom-based, cart-based, or bed-based, the most recent systems approach robotic surgery from a similar perspective. They are big, bulky, and take the surgeon away from the center of the operating theatre, where he or she needs to be.
As a result, surgeons are no longer in the sterile field and agile, adapting to the dynamic environment, making them reluctant to adopt robotics for more procedures.
In addition, turnover teams are not able to be agile in preparing the theatre for the following procedure, making it incompatible with high volume, bread & butter surgeries like cholecystectomies.?
When it comes to surgical robotics adoption, we believe adaptable is as desirable as intuitive.
At Moon Surgical, we have come up with an entirely new approach.
An approach that provides significant adaptability by keeping the surgeon at the bedside and in control of the operating theatre.
It is a versatile system that can be effective in any procedure where a surgeon desires stability, precision, confidence, and control.
The learning curve is low, and set-up time is inconsequential.
It's the Swiss army knife. It's the smartphone. It's the future.
Stay tuned for more.
Sources:
[2] Intuitive Surgical, 2021 JP Morgan Presentation,?https://isrg.intuitive.com/static-files/6fe4e1b5-a282-4cf2-810c-eafc79281ffa
[3] J&J Q3 Earnings Call via Mass Device,?https://www.massdevice.com/johnson-johnson-hits-snag-in-ottava-surgical-robot-development/
[4] Robotic Assisted Surgery, Prostate Volumes,?Analysis: Leave Robotic Prostatectomy in the Hands of Experts | MDedge (the-hospitalist.org)
[5] Khorgami Z, Li WT, Jackson TN, Howard CA, Sclabas GM. The cost of robotics: an analysis of the added costs of robotic-assisted versus laparoscopic surgery using the National Inpatient Sample. Surg Endosc. 2019 Jul;33(7):2217-2221. doi: 10.1007/s00464-018-6507-3. Epub 2018 Oct 16. PMID: 30327915.?https://pubmed.ncbi.nlm.nih.gov/30327915/
[6] Fiona Haig et al. BMJ Surg Interv Health Technologies 2020;2:e000028,?https://sit.bmj.com/content/2/1/e000028
Michael Vogele, MD Moritz Spiller Alfredo Illanes
International Medtech Consultant
2 年Great summary Anne, and thanks for sharing! I have followed very closely Robotic Surgery since 1999 when I first sat behind a DaVinci Console. At the time Intuitive Surgical was focussing on Cardiac Bypass Surgery. At the time little interest was shown in the technology by surgeons who felt they did not need to spend $1.5M to do an anastomosis. The great break through was forienting towards the Prostate at a time when many surgeons were experiencing significant challenges with the development of the Laparoscopic Radical Prostatectomy procedure. It was from about 2006 that the Intuitive Surgical took off and since then has accellerated towards other surgical procedures with device line extensions. The key to their success was though to find a clinical need or respond to the surgical challenge. 20 years later the opportunity for Robotic Assisted Surgery remains massive and there is plenty of room for multiple market entrants thanks to the fine pioneering work by Intuitive Surgical.
Helping Medtech Grow Sales Pipeline & Find Investors Using Social Media |??? Host of MedTech's #1 Podcast | Proud Husband & Father | Avid Reader | Jiu Jitsu @Carlson Gracie | Mentor | Coach
2 年Fantastic piece Anne Osdoit Excited to see what Moon Surgical is building. Any potential reveals at #jpm2022 ?! ??
Validation and Project Engineer at Castle Bravo Ltd
2 年The key to wider scale adoption is to make robotic surgery far superior to the manual alternative. For example: - Positional accuracy at least an order of magnitude better than any surgeon can achieve - with automatic compensation for mechanical wear. - Semi autonomous operation in that the system recognises the structures it is inside. The surgeon only needs to take direct control at critical points, reducing fatigue, similar to an aircraft autopilot.
CEO of Lifeblood | MedTech Executive Recruiter, Investor, and Board Member
2 年Anne Osdoit’s content and updates on Moon Surgical and the “smart tools” / surgical robotics industry are disruptively insightful on where these technologies are headed and need to go for high adoption rates.